Healthcare Provider Details

I. General information

NPI: 1457748782
Provider Name (Legal Business Name): ALLEGRA VANESSA MCDONALD FADEYI PHARMD, CGP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ALLEGRA MCDONALD FADEYI

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 ROCKY FIELD DR
CORDOVA TN
38018-6550
US

IV. Provider business mailing address

643 ROCKY FIELD DRIVE
CORDOVA TN
38018-6550
US

V. Phone/Fax

Practice location:
  • Phone: 804-651-6429
  • Fax:
Mailing address:
  • Phone: 804-651-6429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number36005
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberP-11728
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number0202205262
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: